thrombocytopenia

[militarymd]

Had another case just before my ERCP....

50's guy with CLL in remission but has developed immune related thrombocytopenia refractory to ALL medical therapy....coming to the OR for lap splenectomy.

Plt count>>>>>> 2

He has chronic GI bleeds...just got transfused up to 10/30 before coming to the OR..

In preop...fat lip which is oozing...bleeding gums....oozing from everywhere else...

Oh...and he's kind of fat with a marginal looking airway sporting a beard....

Blood and platelets available... plan is platelets after spleen is out.

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[Noyac]

Had another case just before my ERCP....

50's guy with CLL in remission but has developed immune related thrombocytopenia refractory to ALL medical therapy....coming to the OR for lap splenectomy.

Plt count>>>>>> 2

He has chronic GI bleeds...just got transfused up to 10/30 before coming to the OR..

In preop...fat lip which is oozing...bleeding gums....oozing from everywhere else...

Oh...and he's kind of fat with a marginal looking airway sporting a beard....

Blood and platelets available... plan is platelets after spleen is out.

Fun Fun Fun

 

[jetproppilot]

Had another case just before my ERCP....

50's guy with CLL in remission but has developed immune related thrombocytopenia refractory to ALL medical therapy....coming to the OR for lap splenectomy.

Plt count>>>>>> 2

He has chronic GI bleeds...just got transfused up to 10/30 before coming to the OR..

In preop...fat lip which is oozing...bleeding gums....oozing from everywhere else...

Oh...and he's kind of fat with a marginal looking airway sporting a beard....

Blood and platelets available... plan is platelets after spleen is out.

Geez, Mil.

Time for a cuppla martinis after those cases, huh?

 

[militarymd]

So here's what I did. See what you guys think. There isn't a lot of literature on this but:


1) 4 grams of Amicar infused over the first hour of the case
2) 0.3 mcg/kg of ddavp infused prior to the start of the case.

The surgeon is an excellent surgeon. He normall does lap spleens in less than 1 hour....he took his time with this one....essentially no blood loss.

Platelets given after spleen was taken out....patient did fine.

 

[militarymd]

Oh and I gave afrin to both nostrils just in case we had difficulty with his airway....but the crna tubed him with no blood loss.

 

[nimbus]

I've never seen platelets that low but your experience mimics my own. Unless there is a large raw vascular bed, patients with platelets as low as 30k seem to do fine. Same goes for patients on therapeutic doses of heparin (not overdosed) and those on coumadin with INR up to 2-2.5. I wouldn't go around sticking needles in their backs but they usually don't bleed uncontrollably during surgery.

On the other hand, Plavix seems like nasty stuff. Whenever we get some old fart on Plavix who comes in with a head bleed or hip fracture, they bleed like stuck pigs.

 

[seattledoc]

what's the deal with ddavp? How does that come into play for this case. Did I dose off during that pharmacology lecture?

 

[militarymd]

what's the deal with ddavp? How does that come into play for this case. Did I dose off during that pharmacology lecture?

You didn't miss anything in class.

However, ddavp appears to be a non-specific, non blood component pro-coagulant....even in patients without VWD.......I have anecdotal experience with it decreasing bleeding....so weighed the risk/benefit ratio in this patient at high risk of bleeding and treated empirically with the drug.

I know there is not much published data or guidelines to support its use....that's one of the reasons, I'm asking around to see if anyone knows better and thinks otherwise.

 

[Noyac]

I can't really comment on the DDAVP here but I doubt that I would have given it just b/c I would have felt that its benefits would have been minimal. I have done cases like this and the few plts that are circulating are still quite effective. If the surgeon is skilled, I don't really do much until the spleen is out. Then I start the plts. I really haven't seen these pts do bad or bleed much.

 

[sdn1977]

Actually, I think the work on desmopressin altering blood coagulation was done by a guy named Mannucci - I think it was reported in "Blood" (sorry - I don't know how to underline a citation in this forum) - 1988 or 89.....anyway...if I remember correctly, the mechanism is purported to involve the secretion of von Willebrand factor from vascular endothelial cells & of factor VIII from hepatocytes. I don't know if that was ever documented. I'll have to pursue the topic further since I don't keep up on it. If I find anything more recent, I'll let you know.....

 

[meddog1]

I would have done what you did - transfuse with PLTs (up to 50K), check coags and give factors PRN. I don't think I would do all that other fancy stuff with Desmopressin unless I got hosed during the case.

 

[VentdependenT]

nova seven baby

you can use all that crap you want but without platelets to form a clot its pretty useless eh?

we did a hip pin removal in a teenager whose platelet count was 7 (cbc was done on accident by preop nursing). no clinical signs of bleeding. no hx of any oozing wounds. no problems with placing the pin in the first place. it was felt that maybe the edta in the tube caused a pseudothrombocytopenia (clumping of platelets). So went ahead with the case.

anyways, blood looks like its clotting in field. hematoma develops afterwards. rpt plates 4....uh oh. turns out that this young guy developed some sort of leukemia between his surgeries. blows man.

 

[The_Sensei]

... I'm asking around to see if anyone knows better and thinks otherwise.

Than you?!?!? I doubt it......

 

[The_Sensei]

As an aside, one of the cardiac surgeons with whom I worked would routinely give DDAVP post op for ALL his OPBABGs. Sweared it decreased their incidence of bleeding post-op.

 

[militarymd]

Originally Posted by militarymd
... I'm asking around to see if anyone knows better and thinks otherwise.

Than you?!?!? I doubt it......

 

[Noyac]

How about activated factor 7? Any body using this or have experience with it?

 

[nimbus]

How about activated factor 7? Any body using this or have experience with it?

Some of our trauma patients get it just before they die in the ICU. I have not been impressed to date but part of the problem may be that its usage is so restricted by our pharmacy and P+T committee that the patients don't get it until they are making the last arc around the drain.

 

[SilverStreak]

You didn't miss anything in class.

However, ddavp appears to be a non-specific, non blood component pro-coagulant....even in patients without VWD.......I have anecdotal experience with it decreasing bleeding....so weighed the risk/benefit ratio in this patient at high risk of bleeding and treated empirically with the drug.

I know there is not much published data or guidelines to support its use....that's one of the reasons, I'm asking around to see if anyone knows better and thinks otherwise.

I guess I think of in more simplistic terms, but my thoughts were that is causes vasoconstriction in the vasular beds, which will lead to decreased bleeding. Is that not correct?

 

[militarymd]

I guess I think of in more simplistic terms, but my thoughts were that is causes vasoconstriction in the vasular beds, which will lead to decreased bleeding. Is that not correct?

ddavp is not the same as vasopressin

it causes release of vonwillebarnd factor...and makes what platelets you have work "better"

 

[MTGas2B]

How about activated factor 7? Any body using this or have experience with it?

Had a patient last year, had a pp whipple for pancreatic head mass. Turned out to be autoimmune pancreatitis. Had a very unexpected blood loss post-op, this is at a hospital that normally does pp whipples with one 18 gauge IV as the only access. Turns out he had developed an auto immune factor VIII deficiency. After he exhasusted all the available porcine VIII we could get our hands on, he developed a small stroke. Came to the unit. Our hematologist consulted with the Puget Sound Blood Center, they decided to give him NovoSeven something like q4, then q6 hours for over a week. That's not a typo, 4 to 6 times per day! What is that stuff, like $2000 a pop? It didn't work. Maybe it bought him a day or two. Who knows. Sad case.

 

[SilverStreak]

ddavp is not the same as vasopressin

it causes release of vonwillebarnd factor...and makes what platelets you have work "better"

I see, one of our heart surgeons used to use it for oozing CABs as well, it was explained to me that it was a drug that had a pressor/anti bleeding combo effect. I've never used it myself, so I haven't really read up on it, but I guess if you're platelets are working better and you're not bleeding loosing volume then you will have a better bp.

This is off the orginal topic, but how many cases of HIT is everyone seeing? It seems like lately we are having more and more cases of possible HIT. Sometimes surgery wants to just sit back and wait and watch while the platelets drop, sometimes we have a good explanation for decreased platelets if pt comes out on IABP, but lately we've gotten a few hemotology consults because we had one that surgery was "watching" post op for HIT that ended up with a DVT.

Another patient had a definite HIT dx back in 2000, came in for a redo CAB this time around, had negative antibodies, but clotted off one of his fems the first time and almost lost his leg. Surgery was very proactive on him, he saw hemotology pre op, and immediately post op. I was just wondering if there's not some type of research for an alternative to heparin for bypass in this type of patient we know has had a previous bad reaction to heparin.

It's a scary thing because they almost never do well, end up on refludan or argatroban and then have problems from these drugs.

 

[sdn1977]

Some of our trauma patients get it just before they die in the ICU. I have not been impressed to date but part of the problem may be that its usage is so restricted by our pharmacy and P+T committee that the patients don't get it until they are making the last arc around the drain.

Too true! Novo Seven is expensive, compared with ddavp. I don't know if there are any trials in the US, but in Europe it has been used quite a bit cases like this. I think from the few case reports, the dose for treating thrombocytopenia is unclear & speed is of the essence - which is why perhaps your outcomes are so poor.

Its a recombinant product & my facility does not keep it unless we know in advance we have a pt scheduled who has one of the bleeding disorders which would make them a candidate for its use. So...it would not be readily available for use in the OR at any given time.

It may find a place when used for these situations, but until the dose & pt population are more clearly defined, it hard to rationalize the cost.